Datasets:

ridhomhd

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MedMCQA-filtered

like 0

7733ac35-3c54-4a58-b7eb-bc6b9b8e21d5

All are proved to delay or prevent diabetes in those with impaired glucose tolerance, except

Lifestyle modification

Metformin

Orlistat

Atorvastatin

multi

Intensive changes in lifestyle (diet and exercise for 30 min/d five times/week) in individuals with IGT prevented or delayed the development of type 2 DM by 58% compared to placebo. In the same study, metformin prevented or delayed diabetes by 31% compared to placebo.A number of agents, including a-glucosidase inhibitors, metformin, thiazolidinediones, GLP-1 receptor pathway modifiers, and orlistat, prevent or delay type 2 DM but are not approved for this purpose. Pharmacologic therapy for individuals with prediabetes is currently controversial because its cost-effectiveness and safety profile are not known. Ref: Harrison 19e pg: 2406

Medicine

Endocrinology

9a226d67-43e9-4c94-87e2-5f68df1b85b8

A 35-year-old Insulin Dependent Diabetes Mellitus (IDDM) patient on Insulin for the past 10 years com- plains of gradually progressive painless loss of vision. Most likely he has

Cataract

Vitreous haemorrhage

Total rhegmatogenous retinal detachment

Tractional retinal detachment not involving the macula

multi

(A) Cataract> Patients present with chronic, slowly progressive and generally painless visual loss. The reduction in vision is usually bilateral, though frequently asymmetrical, and occurs over weeks to years.> More common conditions that cause gradual loss of vision can be divided into two groups based on the reversibility of the visual loss.> Cataracts, refractive error, corneal blindness and early diabetic macular edema are generally reversible.> Optic atrophy, glaucoma, retinal degeneration and age-related macular degeneration usually cause permanent loss of vision.> Senile cataract occurs early and more frequently in diabetics.

Ophthalmology

Miscellaneous

e025bee6-cd7d-4ae8-8803-efa9d84bba52

In benign hypeension commonest vascular pathology is

Atherosclerosis

Fatty mfilitraion of intima

Fibmoid necrosis

Hyaline aeriosclerosis

single

In smaller aeries (< 1 mm), hyaline aeriosclerosis occurs in the wall, the lumen narrows and aneurysms may develop. Widespread atheroma develops and may lead to coronary and cerebrovascular disease, paicularly if other risk factors (e.g. smoking,diabetes, hyperlipidaemia,) are present.These structural changes in the vasculature often perpetuate and aggravate hypeension by increasing peripheral vascular resistance and reducing renal blood flow, thereby activating the renin-angiotensin-aldosterone axis. ref:davidson&;s principles and practices medicine,ed 21,pg no 624

Medicine

C.V.S

3592515e-7674-4702-86a9-761d056c35f4

Nodular masses have developed in the periaicular tissue of the proximal and distal interphalangeal joints of the right hand of a 58-year-old man with a 10-year-history of gout. Which of the following choices best describes the characteristics of these masses?

Pathognomonic lesion of chronic gout

Histologically similar to a rheumatoid nodule

Contains weekly positives birefringent monosodium urate crystals

Associated with fibrinoid necrosis

multi

A 58-year-old man with a 10-year history of gout and nodular masses in the periaicular tissue of the proximal and distal interphalangeal joints of his right hand has tophus formation, which is pathognomonic for chronic gout. Tophi are deposits of monosodium urate (MSU) crystals in tissue. Gouty ahritis is a heterogeneous group of disorders characterized by hyperuricemia, recurrent attacks of acute ahritis, the formation of deposits of MSU (tophi), and uric acid urolithiasis. It is the most common inflammatory ahritis in men older than 30 years. Gout is a multifactorial inheritance caused by a combination of genetic susceptibility and the effect of ceain environmental factors (e.g., alcohol, eating red meats). Hyperuricemia is associated, but not synonymous, with gout because some patients with gout have normal uric acid levels. Primary hyperuricemia with gout refers to hyperuricemia that is a consequence of a disorder in uric acid metabolism that results from (1) decreased excretion (most common mechanism), (2) increased production, or (3) a combination of the two. Secondary hyperuricemia associated with gout can be caused by the same mechanisms as primary gout. There are secondary associations with diabetes mellitus, alcoholism, polycythemia rubra vera, leukemia, multiple myeloma, diuretic therapy, and the treatment of disseminated carcinomas. Ref: Maheshwari 9TH ED pg 293.

Orthopaedics

Joint disorders

b68a8ce3-ba19-4b63-8106-68677df88746

The following is true about Nesidioblastosis except ?

Presents with hypoglycemic attacks

More common in adults than in children

Histopathology shows hyperplasia of islet cells

Diazoxide is used for treatment

multi

Nesidioblastosis is a controversial medical term for hyperinsulinemic hypoglycemiaattributed to excessive insulin production by pancreatic beta cells that have an abnormal microscopic appearance.The abnormal microscopic features of the tissue included the presence of islet cell enlargement, pancreatic islet cell dysplasia, beta cells budding from ductalepithelium, and islets in close proximity to ducts. In recent years, the term has been revived to describe a form of acquired hyperinsulinism with beta cell hyperplasia found in adults, especially after gastrointestinal surgery. Evidence of mechanisms explaining the ability of weight loss surgery to induce modern-day nesidioblastosis has yet to be found; any such mechanisms are of intense interest to diabetes researchers. Differential diagnosis of endogenous hyperinsulinism in adults : Reference: GHAI Essential pediatrics, 8th edition

Pediatrics

Endocrinology

9793f065-3f8d-45a0-96d4-7be5a1ee2687

Which of the following is not a cause of absent ankle jerks and up-going plantars?

Freidreich’s ataxia

B12 deficiency

MS

Cord compression

single

Causes of absent ankle jerks and upgoing plantars is a common question as it implies both upper and lower motor neuron involvement. The more common single causes include cord compression involving both the cord (UMN) and nerve ganglia roots (LMN) as well as subacute combined degeneration of the cord. Other more common causes include the presence of more than one pathology, e.g. stroke (UMN) with superimposed peripheral neuropathy (LMN) — usually in a diabetic patient. In Friedrich’s ataxia, both cord and peripheral nerve involvement accompany cerebellar degeneration. These patients also have sensory loss, pescavus and may have complications such as diabetes and hypertrophic cardiomyopathy. Multiple sclerosis may cause a mixture of pyramidal signs (UMN), sensory loss (dorsal columns) and ataxia (cerebellum), but will never involve the LMN.

Unknown

63c7d14b-0d0b-42ab-be84-4630ae1c63aa

Complication (s) of obesity is /are

Venous ulcer

Pulmonary embolism

Moality

Prostate cancer

single

.Complications of obesity General: Difficulty in work, fatigue, depression, back pain, ahritis and gout Cardiovascular: Hypeension, stroke, thrombophlebitis, pulmonary embolism Pulmonary: Hypoventilation, poor respiratory effo GIT: Hiatus hernia with reflux, changes in liver, pancreatitis, gallstones Endocrine: Diabetes mellitus. ref:SRB&;s manual of surgery,ed 3,pg no 90

Surgery

Urology

82eb7b56-02fc-4e20-962a-3b77d8b1c132

Most common organism involved in urinary catheter induced urinary tract infection is -

E.coli

Pseudomonas

Staphylococcus epidermidis

Proteus

single

Most commonly involved organism in causing urinary tract infection is E. Coli. Risk factors - More common in females Recent use of a diaphragm with spermicide, frequent sexual intercourse. Maternal history of diabetes ,UTI and incontinence . Obstruction in urine flow(calculi,malignancies) Incomplete voiding(residual urine) Foriegn body in urinary tract (catheter, calculi) Ref:Harrison 20 th edition pg no 969,970

Medicine

Kidney

fad9bbeb-7d85-4df3-82a8-91b7f7fd239a

Conn&;s syndrome it characterised by all except -

Polyuria

Polydipsia

Weakness

Anasarca

multi

Conn syndrome is characterused by primary hyperaldosteronism by a aldosterone producing adenoma(APA). The clinical hallmark of mineralocoicoid excess is hypokalemic hypeension; serum sodium tends to be normal due to the concurrent fluid retention, which in some cases can lead to peripheral edema.and in severe cases, it may lead to anasarca Hypokalemia can be exacerbated by thiazide drug treatment, which leads to increased delivery of sodium to the distal renal tubule, thereby driving potassium excretion. Severe hypokalemia can be associated with muscle weakness, ove proximal myopathy, or even hypokalemic paralysis; polyuria (secondary to renal tubular damage which produces nephrogenic diabetes insipidus). Severe alkalosis contributes to muscle cramps and, in severe cases, can cause tetany. Reference : page 2319 Harrison&;s Principles of Internal Medicine 19th edition

Medicine

Endocrinology

5d00669c-751c-4f32-acba-abf86445487b

A perimenopausal woman presents with increasing swallowing difficulty and fatigue. Physical examination reveals that her thyroid is enlarged (palpable goiter). Laboratory examination of her serum reveals T4 of 4.9 mg/dL, free T4 of 2.5 ng/dL, and TSH of 5.5 mIU/mL. No thyroidstimulating immunoglobulins are identified in the serum, but antimicrosomal antibodies are present. Which one of the listed histologic findings, if present in a thyroid biopsy from this individual, would be most consistent with a diagnosis of Hashimoto's thyroiditis?

Lymphocytic infiltrate without follicle formation

Intense lymphoplasmacytic infiltrate with lymphoid follicles and scattered oxyphilic cells

Hyperplasia of follicular cells with scalloping of colloid at the margin of follicles

Granulomatous inflammation with multinucleated giant cells surrounding fragments of colloid

multi

Four types of thyroiditis may be associated with hypothyroidism. Hashimoto's thyroiditis, one of the autoimmune thyroid diseases, is associated with the HLA-B8 haplotype and high titers of circulating autoantibodies, including antimicrosomal, antithyroglobulin, and anti-TSH receptor antibodies. This abnormality is not uncommon in the United States. Histologically, there is infiltration of the thyroid stroma by an intense lymphoplasmacytic infiltrate, with the formation of lymphoid follicles and germinal centers. This produces destruction and atrophy of the follicles and transforms the thyroid follicular cells into acidophilic cells. There are many different names for these cells, including oxyphilic cells, oncocytes, Huhle cells, and Askanazy cells. Not uncommonly, patients develop hypothyroidism as a result of follicle disruption, and the manifestations consist of fatigue, myxedema, cold intolerance, hair coarsening, and constipation. Rarely, cases of Hashimoto's thyroiditis may develop hypehyroidism (Hashitoxicosis), while the combination of Hashimoto's disease, pernicious anemia, and type I diabetes mellitus is called Schmidt's syndrome. This is one type of multiglandular syndrome. Although subacute thyroiditis and Riedel's thyroiditis may have similar symptoms to Hashimoto's thyroiditis, biopsy findings in these disorders are distinctly different. Subacute (de Quervain's, granulomatous, or giant cell) thyroiditis is a self-limited viral infection of the thyroid. It typically follows an upper respiratory tract infection. Patients develop the acute onset of fever and painful thyroid enlargement, and may develop a transient hypothyroidism. Histologically there is destruction of the follicles with a granulomatous reaction and multinucleated giant cells that surround fragments of colloid. One-half of patients with Riedel's thyroiditis are hypothyroid, but, in contrast to the other types of thyroiditis, microscopic examination reveals dense fibrosis of the thyroid gland, often extending into extrathyroidal soft tissue. This fibrosis produces a rock-hard enlarged thyroid gland that may produce the feeling of suffocation. This combination of signs and symptoms may be mistaken clinically for a malignant process. Additionally, these patients may develop similar fibrosis in the mediastinum or retroperitoneum. Subacute lymphocytic thyroiditis is also a self-limited, painless enlargement of the thyroid that is associated with hypothyroidism, but that lacks antithyroid antibodies or lymphoid germinal centers within the thyroid Hashimoto's thyroiditis Reference: Robbins & Cotran Pathologic Basis of Disease, 9edition

Pathology

Endocrinology

0cf61ffb-7b29-4cfb-8a69-aa52311a97a5

Glucose is conveed to sorbitol by

Aldolase B

Aldose reductase

Sorbitol Dehydrogenase

UDP galactose 4 epimerase

single

In lens, the enzyme aldose reductase reduces monosaccharides to corresponding sugar alcohols; glucose to sorbitol and galactose to galactitol. POLYOL PATHWAY OF GLUCOSE - Sorbitol is very poorly absorbed from intestine. It involves the reduction of glucose by aldose reductase to sorbitol, which can then be oxidized to fructose. This would amount to the interconversion of glucose to fructose. Glucose when conveed to sorbitol, cannot diffuse out of the cell easily and gets trapped there. Sorbitol is normally present in lens of eyes. But in diabetes mellitus, when glucose level is high, the sorbitol concentration also increases in the lens. This leads to osmotic damage of the tissue and development of cataract. Galactitol also causes cataract. REF: DM VASUDEVAN TEXTBOOK OF BIOCHEMISTRY, SIXTH EDITION, PG.NO.,119,588.

Biochemistry

Metabolism of carbohydrate

85321392-bda2-4914-95b3-eff5cfd6e5f0

Delayed wound healing is seen in all except:

Malignancy

Hypeension

Diabetes

Infection

multi

Factors influencing healing of wound. site structure involved mechanism of wounding contamination loss of tissue local factors Systemic factors Factors that inhibit wound healing LOCAL FACTORS Infections Ischemia Foreign body Hematoma Movement Mechanical stress Necrotic tissue Tissue tension Large defect SYSTEMIC FACTORS Diabetes mellitus Ionizing radiations & temperature Advanced age & Malnutrition Vitamin A & C deficiency Mineral ZINC & IRON deficiencies Drugs( Steroids, Doxorubicin) Jaundice Uremia Malignancy HIV and immunosuppressive disease neuropathies

Surgery

Wound Healing, Tissue Repair and Scar

3b3bd69c-21df-487c-9216-1988c8c288ee

Lactic acidosis is not seen in -

Methanol poisoning

Respiratory failure

Circulatory failure

Tolbutamide

single

An increase in plasma l-lactate may be secondary to *poor tissue perfusion (type A)--circulatory insufficiency (shock, cardiac failure), severe anemia, mitochondrial enzyme defects, and inhibitors (carbon monoxide, cyanide) * aerobic disorders (type B)-- malignancies, nucleoside analogue reverse transcriptase inhibitors in HIV, diabetes mellitus, renal or hepatic failure, thiamine deficiency, severe infections (cholera, malaria), seizures, or drugs/toxins (biguanides, ethanol, methanol, propylene glycol, isoniazid, and fructose). *Unrecognized bowel ischemia or infarction *Pyroglutamic acidemia has been repoed in critically ill patients receiving acetaminophen, which is associated with depletion of glutathione. d-Lactic acid acidosis, which

Medicine

Fluid and electrolytes

daea0b5f-6755-4d65-8e47-4312cbb29729

In addition to the effects of weight loss, the resolution of type 2 diabetes mellitus after the gastric sleeve procedure and RYGB is thought to be contributed to by ?

Reduced ghrelin production

Increased secretion of glucagon-like peptide-1 (GLP-1)

Appetite suppression

All of the above

multi

Gastrectomy removes much of the Ghrelin-producing poion of the stomach, leading to weight loss after both gastric sleeve and RYGB procedures. GLP-1, is dramatically increased after RYGB, and after gastric sleeve

Surgery

Robotics, Laparoscopy and Bariatric Surgery

e3b5fcf8-7303-4b48-9382-a123cc4676e0

Not seen in cushing's syndrome: March 2009

Hypeension

Weight gain

Hirsutism

Hypoglycemia

single

Ans. D: Hypoglycemia Symptoms of Cushing's syndrome include rapid weight gain, paicularly of the trunk and face with sparing of the limbs (central obesity). A common sign is the growth of fat pads along the collar bone and on the back of the neck (buffalo hump) and a round face often referred to as a "moon face". Other symptoms include hyperhidrosis (excess sweating), telangiectasia (dilation of capillaries), thinning of the skin (which causes easy bruising and dryness, paicularly the hands) and other mucous membranes, purple or red striae (the weight gain in Cushing's syndrome stretches the skin, which is thin and weakened, causing it to hemorrhage) on the trunk, buttocks, arms, legs or breasts, proximal muscle weakness (hips, shoulders), and hirsutism (facial male-pattern hair growth), baldness and/or cause hair to become extremely dry and brittle. In rare cases, Cushing's can cause hypercalcemia, which can lead to skin necrosis Other signs include polyuria (and accompanying polydipsia), persistent hypeension (due to coisol's enhancement of epinephrine's vasoconstrictive effect) and insulin resistance (especially common in ectopic ACTH production), leading to hyperglycemia (high blood sugar) which can lead to diabetes mellitus. Cushing's syndrome due to excess ACTH may also result in hyperpigmentation, such as acanthosis nigricans in the axilla. This is due to Melanocyte-Stimulating Hormone production as a byproduct of ACTH synthesis from Pro-opiomelanocoin (POMC). Coisol can also exhibit mineralcoicoid activity in high concentrations, worsening the hypeension and leading to hypokalemia (common in ectopic ACTH secretion). Fuhermore, gastrointestinal disturbances, oppounistic infections and impaired wound healing (coisol is a stress hormone, so it depresses the immune and inflammatory responses). Osteoporosis is also an issue in Cushing's syndrome

Medicine

89457faa-bd2c-444f-9569-b0f0e695bde9

Small fiber neuropathy is seen in?

HIV

Vitamin B12 deficiency

AIP

Cisplatin toxicity

multi

Small unmyelinated peripheral nerve fibers, Categorized as C fibers, In skin and organs. Innervate the skin (somatic fibers) , Help to control autonomic function. Causes of Small Fiber Neuropathy: 1. Diabetes mellitus 2. Leprosy 3. Amyloidosis 4. Tangier's disease 5. Sjogren syndrome 6. HIV 7. Sarcoidosis

Medicine

Channelopathies and Neuropathies

4b062773-5829-45c2-97d7-3a73e9b92b11

High-risk factor for gestational hypeension include all except:

BP 150\/100 mm of Hg

Gestation age < 30 weeks

IUGR

Polyhydramnios

multi

polyhydaminos is defined as excess of amniotic fluid more than 2000ml.The causes are fetal structural malformations,chromosomal anomalies,multiple pregnancy,immune hydrops fetalis,sacrococccygeal teratoma,maternal diabetes,and maternal substance abuse,chorioangioma of placenta. Refer page no 213 of Text book of obstetrics,sheila balakrishnan,2 nd edition.

Gynaecology & Obstetrics

Medical, surgical and gynaecological illness complicating pregnancy

f9d820d2-0e81-4cd0-9129-0244bb58c969

Transfusion reaction and erythroblastosis fetalis are-

Type I hypersensitivity

Type II hypersensitivity

Type III hypersensitivity

Type IV hypersensitivity

single

Ans. is 'b' i.e., Type II hypersensitivity Schick test is an example of type III hypersensitivity or immune-complex reaction.HYPERSENSITIVITYType I (IgE mediated)Type II (IgG IgM ando Eczemacomplement mediated)o Hay fevero Blood transfusion reactionso Asthmao Erythroblastosis fetaliso Atopyo Autoimmune hemolytico Urticariaanemia or thrombocytopeniao Anaphylactic shockor agmulocytosiso Acute dermatitiso Pemphigus vulgariso Theobald smitho Good pasture syndromephenomenono Bullous pemphigoido Prausnitz Kusntero Pernicious anemia(PK) reactiono Acute rheumatic fevero Casonis testo Diabetes mellituso Schultz-Daleo Graves diseasephenomenono Myasthenia gravisHYPERSENSITIVITYType III flgG IgM. complementType IV (Cell mediated)and leucocyte mediated)o Tuberculin testo Local-Arthus reactiono Lepromin testo Systemic-serum sicknesso Sarcoidosiso Schick testo Tuberculosiso Polyarteritis nodosa (PAN)o Contact dermatitiso Rheumatoid arthritiso Granulomatous inflammationo SLEo Type I lepra reactiono Acute viral hepatitiso Patch testo Penicillamine toxicityo Temporal arteritiso Hyperacute graft rejectiono Jones mote reactiono Type 2 lepra reaction (ENL)(cutaneous basophilic HSN)o Hypersensitivity pneumonitiso Graft rejectiono R.A.o Fairleys testo Infective endocarditiso Frie's testo Henoch schonlein purpura o Glomerulonephritis

Pathology

Blood

d5323a1f-be93-4db3-bec1-cc413b8b27f2

Water Deprivation Test is used to assess

Glomerular Function

Proximal Tubular Function

Distal Tubular Function

Renal Plasma Flow

single

Answer is C (Distal Tubular Function) Water Deprivation Test is used to assess Distal Tubular Function. Water Deprivation Test Water deprivation test is used to assess the tubule's ability to concentrate urine. When a normal person is deprived of water, ADH secretion occurs, which acts on the distal tubule and collecting ducts, making them freely permeable to water, allowing reabsorption of water from these segments, thereby producing concentrated urine. Inability to concentrate urine during the water deprivation test thereby suggests dysfinction of distal tubules and helps to identifi, nephrogenic diabetes insipidus.

Medicine

0dbf468f-8c10-4aec-8e5a-6ab9ddd25c05

Commonest fungal infection of the female genitalia in diabetes is:

Cryptococcal

Madura mycosis

Candidial

Aspergellosis

single

C i.e. Candidial

Skin

04de54ce-da75-4040-97fb-a43662ee09ff

Increased sweat chloride is seen in all except –

Ectodermal dysplasia

Nephrogenic diabetes insipidus

Glucose 6 phosphatase deficiency

Obesity

multi

Increased sweat chloride is seen in - Cystic fibrosis                                                                                                                       Malnutrition                                                                                                                         Pancreatitis                                                                                                                            Hypothyroidism Familial cholestasis Ectodermal dysplasia Fucosidosis Mucopolysaccharidosis   Untreated adrenal insufficiency (Addison disease) Hereditary nephrogenic diabetes insipidus  Hypoparathyroidism Glucose-6-phosphatase deficiency

Pediatrics

2949130e-edee-4fcb-98ef-315340ac86ba

Most common cause of neuropathic joint:

Diabetes

Amyloidosis

Syphilis

Leprosy

single

Ans: a (Diabetes) Ref: Harrison, 16th ed, p. 2060; 17th ed, p. 2180Most common cause of neuropathic joint is diabetesNeuropathic joint (Charcot joint)It is a progressive destructive arthritis associated with loss of pain sensation, proprioception or both.Clinical featuresIt begins as a single joint and then progresses to involve other joints. Swelling is present, loose bodies may be palpated.Joint becomes unstable and subluxation may occur. The amount of pain experienced by the patient is less than that would be anticipated based on the degree of joint involvement.Causes of Charcot jointDiabetes mellitusTabes dorsalisMeningomyelocoele or syringomyeliaAmyloidosisLeprosyPeroneal muscular atrophyCommonly involved joints in various diseasesDiabetes mellitus: Tarsal and metatarsal jointsTabes dorsalis: Knee, hips and anklesSyringomyelia: Glenohumeral joint, elbow and wrist

Medicine

Immunology and Rheumatology

3e10afe5-f8e9-470e-a549-b93f182624b9

A lady presented to your with a history of recurent early pregnancy loss. What are the investigation to be ordered:

VDRL

Toxoplasma serology

Hemogram/Blood grouping

Rubella screening

single

Ans. is C i.e. Hemogram /blood grouping? As discussed in previous answer? Complete blood counts along with platelet count are done in case of recurrent pregnancy loss. VDRL-To test for syphilis Rubella-virus screening are not done because as discussed earlier, infections rarely lead to recurrent Toxoplasma serology pregnancy loss. "Few infection are firmly associated with early pregnancy loss- moreover, if any of these infections are associated with miscarriage, they are even less likely to cause recurrent miscarriage because maternal antibodies usually develop with primary infection. Thus, there appears no concrete indication to screen for infection in asymptomatic women with recurrent miscarriage" "Routine serological lests, cervical cultures and endometrial biopsy to detect genital infections in women with recurrent pregnancy loss cannot be justified. Evaluation should be limited to women with clinical cervicits, chronic or recurrent bacterial vaginosis or other symptoms of pelvic infections" As far as Blood glucose testing is concerned- Neither Novaks, Leon speroff, nor Williams- say that blood glucose levels should be tested in patients with recurrent pregnancy loss - Leon speroff says? " In women with recurrent pregnancy loss, evaluation with blood glucose and HbA,C AIC level is indicated for those with known or suspected diabetes, but otherwise it is unwarranted" So for our exams purposes we have to learn & remember the list of investigations mentioned in previous question in case of recurrent aboions.

Gynaecology & Obstetrics

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A 6-year-old girl has become increasingly lethargic over the past 2 weeks. On examination, she has puffiness around the eyes. Her temperature is 36.9degC, and her blood pressure is 100/60 mm Hg. Laboratory findings show serum creatinine, 0.7 mg/ dL; urea nitrogen, 12 mg/dL; and cholesterol, 217 mg/dL. Urinalysis shows pH, 6.5; specific gravity, 1.011; 4+ proteinuria; lipiduria; and no blood or glucose. The 24-hour urine protein level is 3.8 g. The child's condition improves after glucocorticoid therapy. Which of the following findings by electron microscopy is most likely to characterize this disease process?

Areas of thickened and thinned basement membrane

Effacement of podocyte foot processes

Increased mesangial matrix

Reduplication of glomerular basement membrane

single

A child with nephrotic syndrome and no other clinical findings is most likely to have minimal change disease, a name that reflects the paucity of pathologic findings. There is a fusion of podocyte foot processes, which can be seen only by electron microscopy. This fusion leads to selective proteinuria of low molecular weight proteins (albumin). Variability of basement membrane thickening may be seen in Alport syndrome. The mesangial matrix is expanded in some forms of glomerulonephritis (e.g., IgA nephropathy) and other diseases, such as diabetes mellitus, but not in minimal change disease. Reduplication of the glomerular basement membrane may be seen with membranoproliferative GN. Subepithelial electron-dense humps represent immune complexes and are seen in postinfectious GN.

Pathology

Kidney

8d8d7791-671f-4f50-a958-1c1a85af3928

Which of the following is not a risk factor for cholangiocarcinoma

Thorotrast

Radon

Dioxin

Aflatoxin

single

Risk factors for cholangiocarcinoma Choledochal cyst Primary sclerosing cholangitis Ulcerative colitis. RPC or hepatolithiasis. Biliary enteric anastomosis HBV, HIV, HCV Choledocholithiasis Clonorchis sinensis and opisthorchis viverrini Cirrhosis Radon Asbestos, Nitrosamines, Dioxib(AND). Diabetes, Obesity, OCP's, smoking, Thorotrast, Isoniazid(DOSTI) Ref: Sabiston 20th edition Pgno :1514

Anatomy

G.I.T

586ef1ea-10ea-434c-b773-add47542a822

Osteoporosis is characterized by all the following except -

Decreased bone mineral density

Decreased Serum Calcium, phosphorus and alkaline phosphatase is seen

Glucocorticoids can cause osteoposis

Dorsolumbar spine is the most coomon site of osteoporotic fracture

multi

Ans. is 'b' i.e.. Decreased Serum Calcium, phosphorus and alkaline phosphatase is seen o Osteoporosis is a state of decreased mass per unit volume of a normally mineralized bone. Osteoporosis is the commonest metabolic bone disease. Osteoporosis is characterized by an abnormally low bone mass (low bone density) and defects in bone structure, a combination of which renders the bone unusually fragile and at greater than normal risk of fracture. Bone depletion may be brought about by predominant bone resorption, decreased bone formation or a combination of the two.Causes of osteoporosiso Causes of osteoporosis can be : -In old agePost-menopausal osteoporosis (Type I osteoporosis).Age related senile osteoporosis (Type II osteoporosis)In adults (Pathological)Hypogonadal stateso Turner syndromeo Klienfelter syndromeo Anorexia nervosao Hypothalamic amenorrheao Hyperprolactinemiao Other primary or secondary hypogonadal statesEndocrine disorderso Cushing's syndromeo Hyperparathyroidismo Thyrotoxicosiso Type 1 diabetes mellituso .Acromegalyo Adrenal insufficiencyNutritional and gastrointestinal disorderso Malnutritiono Parenteral nutritiono Malabsorption syndromeso Gastrectomyo Severe liver disease, especially biliary cirrhosiso Pernicious anemiaRheumatologlc disorderso Rheumatoid arthritiso Ankylosing spondylitisHematologic disorders/malignancyo Multiple myelomao Lymphoma and leukemiao Malignancy-associated parathyroid hormone (PTHrP) productiono Mastocytosiso Hemophiliao ThalassemiaSelected inherited disorderso Osteogenesis imperfecto Marfan syndromeo Hemochromatosiso Hypophosphatasiao Glycogen storage diseaseso Homocystinuriao Ehlers-Danlos syndromeo Porphyriao Menkes' syndromeo Epidermolysis bullosaOther disorderso Immobilizationo Chronic obstructive pulmonary diseaseo Pregnancy and lactationo Scoliosiso Multiple sclerosiso Sarcoidosiso AmyloidosisDrugs causing osteoporosiso Glucocorticoidso Cyclosporino Cytotoxic drugso Excessive alcoholo Aromatase inhibitorso Heparino Lithiumo Excessive thyroxineo Aluminiumo GnRh agonistsClinical features of osteoporosiso Osteoporosis is an asymptomatic disorder unless complications (predominantly fractures) occur,o Most common symptom of osteoporosis is back pain secondary to vertebral compression fracture.o Dorso-lumbar spine is the most frequent site.o Other common sites of fracture are lower end radius (Colic's fracture) and fracture neck femur.o Osteoporotic fracture (fragile fractures) are : i) Fracture vertebrae (most common), (ii) Colic's fracture, (iii) Fracture neck femur.o Serum calcium, phosphate and alkaline phosphatase are normal in osteoporosis.Radiological features of osteoporosiso At least 30% of the bone mass must be lost before it becomes apparent on x-ray.o X-ray findings are : -i) Loss of vertical height of a vertebra due to collapse.Cod fish appearance: The disc bulges into the adjacent vertebral bodies so that the disc becomes biconvex.Ground glass appearance of the bones, conspicuous in bones like the pelvis.Singh's index : Singh et al. graded osteoporosis into 6 grades based on the trabecular pattern of the femoral neck trabeculae. Details are outside the scope of this book.Metacarpal index and vertebral index are other methods of quantification of osteoporosis.

Orthopaedics

Metabolic Disorders Leading to Osteosclerosis

1b55184c-f242-4a92-8d7d-73c9c8b21a60

Drug used only for treatment of postprandial hyperglycemia is

Alpha glucosidase inhibitors

Rapaglinide

Sulfonylureas

Metformin

single

Alpha glucosidase inhibitors - effect on both prandial and post prandial sugar ,that act as competitive inhibitors of enzymes needed to digest carbohydrates Rapaglinide is used only for treatment of postprandial hyperglycemia Sulfonylureas is for maintenance of type 2 DIABETES MELLITUS Metformin is drug of choice for treatment of type 2 DIABETES MELLITUS

Pharmacology

Pancreas

84262175-a878-4dca-8836-c9594f099fd2

A 50-year-old obese man with hyperlipidemia, hypertension, and type 2 diabetes mellitus comes to the physician for a routine examination During the visit he asks, “What is my risk of having a heart attack?” While searching your information database, which of the following represents the best study design to address his question?

Case-control study

Case series

Cohort study

Cross-sectional study

single

Social & Preventive Medicine

b9fbc85e-59d5-4b42-8870-45a8f5eba164

Medial calcification is seen in -

Atherosclerosis

Arteriolosclerosis

Monckeberg's sclerosis

Dissecting aneurysm

single

First, see types of arteries Based on their size and structural features, arteries are divided into three types. 1. Large or Elastic arteries Aorta Its large branches, eg. - Innominate, Subclavian, common carotid, iliac. Pulmonary arteries. 2. Medium sized or muscular arteries Small branches of aorta → Coronary, Renal 3. Small arteries and arterioles Within substance of the tissue          Now see their affection - Arteriosclerosis Don’t get confused with atherosclerosis. Arteriosclerosis means hardening of arteries by thickening and loss of elasticity of arterial wall. There are three patterns of arteriosclerosis. 1. Atherosclerosis Characterized by intimal lesions, i.e. atheromas, which project into a vascular lumen and may obstruct it. This is the most common pattern of arteriosclerosis. It involves elastic arteries and large & medium size muscular arteries. 2. Arteriolosclerosis Seen in arterioles of patients with hypertension and diabetes. Two anatomic variants are common hyaline and hyperplastic arteriolosclerosis. 3. Monckeberg medial calcific sclerosis It is seen in small and medium-sized muscular arteries. It is a degenerative and apparently non-inflammatory disease. Media of these arteries becomes calcified. It occurs in patients older than 50 years.

Pathology

40da2f5d-f108-4af3-9506-d3f7601b0fe3

A 48-year-old man presents with recurrent headaches and ahritic pain in his knees of 9 months in duration. He notes that his head size has recently increased. Physical examination reveals a blood pressure of 170/100 mm Hg. The patient is observed to have coarse facial features and a goiter. Urinalysis reveals glucosuria and hypercalciuria. Which of the following is the most likely explanation for this patient's clinical presentation?

Excess growth hormone secretion

Excess parathyroid hormone secretion

Excess prolactin secretion

Hypersecretion of bone morphogenetic protein

single

- Given clinical features are suggestive of Acromegaly; which is d/t increased growth hormone, produced by pituitary adenomas. - C/F of Acromegaly: Enlargement of terminal poions of extremities & jaw Headaches and visual disturbances d/t compression on optic chiasma. Menstrual irregularities in women Diabetes mellitus. 1/3rd have hypeension. Hypercalciuria & renal stones in 1/5th of patients - Somatotroph adenoma that arises in a child or adolescent before the epiphyses close results in gigantism.

Pathology

Miscellaneous

5e9d17bb-fb95-4fd5-94c7-762219f408c1

Causes of papillary necrosis in kidney are/is:

Diabetes mellitus

Sickle cell disease

Analgesic abuse

All

multi

Ans. d (All). (Ref. Robbin's, Pathology, 6th/pg.924)CAUSES OF PAPILLARY NECROSIS (mnemonic--POSTCARD):# Pyelonephritis# Obstructive uropathy# Sickle cell disease# TB and trauma, tubular necrosis, transplant rejection# Cirrhosis (alcoholism, coagulopathy)# Analgesics# Renal vein thrombosis# Diabetes, Dehydration

Pathology

Kidney

e3f23718-cc7c-4369-be21-2e85ecc4ea1c

Not a feature of diabetes mellitus in pregnancy

Postdatism

Hydramnios

Neonatal hyperglycemia

congenital defect

single

Neonatal complications Respiratory distress syndrome Hypoglycemia Polycythemia Hyperbilirubinemia Hyperviscosity Cardiomyopathy Bih trauma Reference: Textbook of Obstetrics; Sheila Balakrishnan, 2nd edition; Page no: 241

Gynaecology & Obstetrics

Medical, surgical and gynaecological illness complicating pregnancy

9c86c6a5-8846-4990-a296-1e840bfe000f

A 78-year-old man with a history of coronary aery disease and an asymptomatic reducible inguinal hernia requests an elective hernia repair. Which of the following would be a valid reason for delaying the proposed surgery?

Coronary aery bypass surgery 3 months earlier

A history of cigarette smoking

Jugular venous distension

Hypeension

single

The work of Goldman and others has served to identify risk factors for perioperative myocardial infarction. The highest likelihood is associated with recent myocardial infarction: the more recent the event, the higher the risk up to 6 months. It should be noted, however, that the risk never returns to normal. A non-Q-wave infarction may not have destroyed much myocardium, but it leaves the surrounding area with borderline perfusion, thus the paicularly high risk of subsequent perioperative infarction. Evidence of congestive hea failure, such as jugular venous distention, or S3 gallop also carries a high risk, as does the frequent occurrence of ectopic beats. Old age (>70 years) and emergency surgery are risk factors independent of these others. Coronary revascularization by coronary aery bypass graft (CABG) tends to protect against myocardial infarction. Smoking, diabetes, hypeension, and hyperlipidemia (all of which predispose to coronary aery disease) are surprisingly not independent risk factors, although they may increase the death rate should an infarct occur. The value of this information and data derived from fuher testing is that it identifies the patient who needs to be monitored invasively with a systemic aerial catheter and pulmonary aerial catheter. Most perioperative infarcts occur postoperatively when the third-space fluids return to the circulation, which increases the preload and the myocardial oxygen consumption. This generally occurs around the third postoperative day.

Anaesthesia

Preoperative assessment and monitoring in anaesthesia

a25051b0-38e2-489b-973f-68488093d961

The common organism isolated in Emphysematous pyeloneohritis is

E. Coli

Proteus

Pseudomonas

Klebsiella

single

Emphysematous pyelonephritis (EPN) is a severe, necrotizing infection of the renal parenchyma causing gas formation within the collecting system, renal parenchyma, and/or perirenal tissues. Also called renal emphysema and pneumonephritis. Gas in the renal pelvis alone, without parenchymal gas, is often referred to as emphysematous pyelitis.EPN most often occurs in persons with diabetes mellitus, especially women.Among the bacteria associated with emphysematous pyelonephritis (EPN), Escherichia coli is isolated in 66% of patients, and Klebsiella species are repoed in 26% of patients. Proteus,Pseudomonas, and Streptococcus species are other organisms found in patients with EPN, and Entamoeba histolytica and Aspergillus fumigatus also have been repoed to cause the disease. Mixed organisms are observed in 10% of patients. Rare organisms such as Clostridium and Candida species have also been isolated in patients with EPN.

Surgery

Urology

6ad72775-cb06-4ae1-8d9f-3d5ac1744674

All are true about diabetic ketoacidosis except?

Raging thirst

It is an early presentation in type 1 DM

Sodium Nitroprusside test is done to detect ketones

Serum bicarbonate > 15 mmol/L

multi

In diabetic ketoacidosis, the elevated blood sugar due to osmotic diuresis leads to polyuria. The stimulation of osmo-receptors will lead to increased thirst. DKA can lead to early presentation of type 1 DM but more frequently occurs in patients with pre-existing diabetes. Serum ketones are present in DKA and detectable at dilutions of 1:8. Urine dipstick using sodium nitroprusside can help in detection but plasma beta hydroxybutyrate is preferred. Serum bicarbonate levels in DKA are <10mmol/L

Medicine

Diabetes Mellitus

b460a831-6fd1-4de7-acb9-6a337d44e908

A 70-year-old patient with long-standing type 2 diabetes mellitus presents with complaints of pain in the left, ear with purulent drainage. On physical examination, the patient is afebrile. The pinna of the left ear is tender, and the external auditory canal is swollen and edematous. The white blood cell count is normal. Which of the following organisms is most likely to grow from the purulent drainage?

Pseudomonas aeruginosa

Streptococcus pneumoniae

Candida albicans

Haemophilus influenzae

single

Ear pain and drainage in an elderly diabetic patient must raise concern about malignant external otitis. The swelling and inflammation of the external auditory meatus strongly suggest this diagnosis. This infection usually occurs in older, poorly controlled diabetics and is almost always caused by P aeruginosa. It can invade contiguous structures including facial nerve or temporal bone and can even progress to meningitis. Streptococcus pneumoniae, H influenzae, and M catarrhalis frequently cause otitis media, but not external otitis. Candida albicans almost never affects the external ear.

Medicine

Infection

cbb4b21d-d4e7-4ddb-ade3-15797a79cc8f

Which type diabetes is HLA associated -

Type I diabetes

Type II diabetes

Malnutrition related type disease

Pregnancy related type diabetes

single

Medicine

6ac71b15-eb6c-4edd-9138-a1fad3ba9dcd

Vitamin deficiency causing optic atrophy -

Vitamin A

Vitamin B

Vitamin C

Vitamin D

single

Ans. is 'b' i.e. Vitamin B Nutritional optic atrophyo The exact mechanism by which nutritional deficits damage the optic nerve has not been elucidated. Although the etiology is likely multifactorial, most clinicians agree that in patients who abuse ethanol and tobacco, malnourish- ment is often present and undemutrition, rather than direct toxicity, is the principal cause of the visual loss. Specific deficiencies of vitamin B-12 (cyanocobalamin), thiamine (vitamin B-1), other B-complex vitamins (riboflavin, niacin, and pyridoxine), and folic acid, as well as reduced systemic levels of other proteins with sulfur-containing amino acids, may play a role.Causes of optic atrophyo Compressive - secondary to papilledema, tumor, bony growth (fibrous dysplasia, osteopetrosis), thyroid eye disease, chiasmal (pituitary etc), optic nerve sheath meningioma, disc drusen, increased intraocular pressure (glaucoma)o Vascular - arteritic and non-arteritic ischemic optic neuropathy, diabeteso Inflammatory - sarcoid, systemic lupus, Behcet's, demyelination (MS), etc.o Infectious - viral, bacterial, fungal infections - herpes, TB, bartonella, etc.o Toxic & nutritional - many medications such as ethambutol, amiodarone, methanol, vitamin deficiency etc.o Metabolic - diabeteso Neoplastic - lymphoma, leukemia, tumor, gliomao Genetic - Autosomal dominant optic atrophy (OPA1), Leber's hereditary optic atrophy, Leber's hereditary optic neuropathy, as a late complication of retinal degneration.o Radiation optic neuropathyo Traumatic optic neuropathy

Ophthalmology

Diseases of the Optic Nerve

ac7b515b-2a8f-4b27-bdd6-104f3f043eb9

Most common cause of CRF in adults is -

TB

HTN

DM

Scleroderma

single

Ans. is 'c' i.e., DM o Diabetes mellitus is the most common cause of Renal failure.

Medicine

Chronic Kidney Disease and Uremia

1e0a4833-c273-448a-b231-87b0e814f308

A 40-year old diabetic patient presents with proptosis of one eye and black eschar over palate. The likely organism is:

Pseudomonas

Candida

E. coli

Mucor

single

Mucormycosis can affect the upper respiratory, pulmonary, cutaneous, gastrointestinal, and central nervous systems. The clinical manifestation of the condition is headache with nasal discharge and sinus pain. Infection quickly spreads from the sinuses to contiguous structures. Ocular involvement manifests as proptosis, periorbital edema, ophthalmoplegia, or vision loss. Angioinvasion by hyphae leads to a black necrotic eschar on the palate or nasal mucosa. Infection spreading from the ethmoid sinus to the frontal lobe can cause obtundation. Mucormycosis in immunocompromised patients typically occurs with spore inhalation or through skin lacerations. Hyperglycemia, usually with related metabolic acidosis, is the most common underlying condition associated with mucormycosis. Rhinocerebral mucormycosis is rapidly fatal and should be suspected in high-risk patients presenting with sinusitis, paicularly those with diabetes and metabolic acidosis. Altered mental status that persists after metabolic abnormalities are corrected suggests possible central nervous system (CNS) infection. Diagnosis is based on histopathology with culture confirmation Treatment requires prompt and aggressive surgical debridement and antifungal therapy with amphotericin B ref - pubmed.com

Medicine

Endocrinology

5d418b64-32ec-4aba-ab80-b521a261e4e3

A pregnant female presented with itching in genital area. What is the MOST common vaginal infection in pregnancy?Gonorrhoea z

Gonorrhoea

Trichomoniasis

Candidiasis

Bacterial vaginosis

single

Candida species are normal flora of the oropharynx, bowel, and vagina. Candida overgrowth of these surfaces may arise in the setting of broad spectrum antibiotics, diabetes mellitus, or HIV infection, resulting in oral thrush, Candida esophagitis, and vaginal candidiasis. High estrogen states, such as pregnancy or oral contraceptive use, are an additional risk factor for vaginal yeast infection. Candida skin infections are often seen in moist, macerated interigenous folds, such as in the groin, perineum (diaper rash), pannus, axillae, and breasts. Ref: Matloff J. (2012). Chapter 192. Candida and Aspergillus. In G.V. Lawry, S.C. McKean, J. Matloff, J.J. Ross, D.D. Dressler, D.J. Brotman, J.S. Ginsberg (Eds), Principles and Practice of Hospital Medicine.

Gynaecology & Obstetrics

dccc20a4-6f29-4123-b06a-034b801eda63

A 8 year old boy presents with recurrent pneumonia since birth. The boy had a history of delayed passage of Meconium at birth. Probable diagnosis is

Kartagener's syndrome

Bronchiectasis

Cystic fibrosis

Hirnchiprung disease

single

Features of Cystic fibrosis Delayed passage of Meconium Recurrent pneumonia Steatorrhea Late onset Diabetes Azoospermia

Pediatrics

905cbee9-53a0-4aac-be66-3c30762b9e84

Which one of the following is closely associated with Myasthenia gravis?

Thymoma

Lymphoma

Adenoma

multi

(A) Thymoma # MYASTHENIA GRAVIS is a neuromuscular disorder characterised by weakness and fatigability of skeletal muscles.> Up to 75% of patients have an abnormality of the thymus; 25% have a thymoma, a tumor (either benign or malignant) of the thymus, and other abnormalities are frequently found.> The disease process generally remains stationary after thymectomy (removal of the thymus).# Disorders Associated with Myasthenia Gravis & Recommended LaboratoryTests> Associated disorders Disorders of the thymus: thymoma, hyperplasia Other autoimmune disorders: Hashimoto's thyroiditis, Graves' disease, rheumatoid arthritis, lupus erythematosus, skin disorders, family history of autoimmune disorder> Disorders or circumstances that may exacerbate myasthenia gravis: hyperthyroidism or hypothyroidism, occult infection, mec ical treatment for other conditions (aminoglycoside antibiotics, quinine, antiarrhythmic agents)> Disorders that may interfere with therapy: tuberculosis, diabetes, peptic ulcer, gastrointestinal bleeding, renal disease, hypertension, asthma, osteoporosis, obesity# Recommended laboratory tests or procedures> CT or MRI of mediastinum> Tests for lupus erythematosus, antinuclear antibody, rheumatoid factor, antithyroid antibodies Thyroid-function tests PPD skin test Chest radiography Fasting blood glucose measurement Pulmonary-function tests Bone densitometry in older patients

Medicine

Miscellaneous

56c8695e-8238-4e3d-a70e-b044810b29ba

Which of the following is associated with hydrocephalus :

Diabetes mellitus

Spina bifida

Breech presentation

All

multi

Ans. is a, b and c i.e. Diabetes; Breech presentation; and Spina bifida Hydrocephalus as we have already discussed is Ventriculomegaly (accumulation of CSF within the ventricles) and increase in head circumference. Since the head size is big in case of hydrocephalus, it cannot accommodate in the lower uterine segment therefore Breech presentation is commondeg. (Option 'd' is correct) ''Breech presentation is found in atleast third of fetuses with hydrocephalus" Hydrocephalus is an impoant cause of dystocia.deg Maternal diabetes mellitus leads to a number of congenital malformations, one of which is hydrocephalus. Hydrocephalus in itself is associated with a number of other anomalies in >50% cases (an exhaustive list of which is given in I don't think you need to mug up all of them. Hydrocephalus is associated with poor fetal prognosis but besides obstructed labour and its consequences there is no other risk to mother. Extra Edge : A study done in U.S. found an association between maternal smoking and hydrocephalus. The risk of recurrence of hydrocephaly after a first affected child is 2%. Management of Hydrocephalus : Detected antenately on USG Associated with other anomalies incompatible with life. No associated anomaly Cephalocentesis by transvaginal/transabdominal technique. Elective cesarean section Note : For details on hydrocephalus I would suggest you to go through of Fernando Arias 2/e, p. 331-332 and not third edition as many impoant details have been chalked out.

Gynaecology & Obstetrics

2775e321-563f-40d6-a735-47202b928f1d

All of the following statements regarding Diabetes Mellitus are true, Except -

Insulin is not used in Type II Diabetes mellitus

Insulin levels may be increased in patients with Type II Diabetes mellitus

Insulin is essential to reverse Diabetic Ketoacidosis

Intravenous Insulin is administered as a sliding scale in the hospital setting

multi

Medicine

73642435-022f-4008-867c-22e392c5f126

Another name for oral thrush is ?

Candidiasis

Herpangina

Vincent's infection

Hand foot and mouth disease

single

Ans. is 'a' i.e., Candidiasis Oral thrush Also called: oral candidiasis It is the fungal infection of the oral cavity. It is caused by candida albicans. It manifests as greyish white patches on the oral mucosa and tongue.\\When wiped off it leaves an erythematous mucosa. This is more common in infants and children. Adults suffering fro diabetes, malignancy, taking broad spectrum oral antibiotics, radiation, cytotoxic drugs or steroids can also be affected. It is treated by topical application of nystatin or clotrimazole. Chronic Hyperophic Candidiasis (Candidial Leukoplakia) Appears as a white patch in the oral cavity which cannot be wiped off. It mostly affects the anterior buccal mucosa just behind the angle of mouth. It is treated by excision of the lesion.

ENT

ab4f8150-c75b-4146-8e3c-99c9fbae18cc

The enzyme responsible for development of Cataract in diabetes is due to

Hexokinase

NADPH+ dependent aldoreductase

Glucokinase

Phosphofructoisomerase

single

NADPH+ dependent aldoreductase is responsible for accumulation of Sorbitol in Lens causing Cataract in Diabetic.

Ophthalmology

4d6d898f-bae6-4e00-a462-0aa2ea2839a0

A child with nephrotic syndrome following an episode of diarrhea presented with acute kidney injury with a creatinine of 4.5. All of the following are possible reasons except?

Excess furosemide

Diarrhea water depletion

Renal vein thrombosis

Steroid induced diabetes

multi

Ans. d. Steroid induced diabetes

Gynaecology & Obstetrics

2032f13e-b3ec-49cc-86b8-7920ca0c20a3

The superficial retinal hemorrhage is seen in which layer of retina?

Inner plexiform layer

Nerve fiber layer

Inner nuclear layer

Outer nuclear layer

single

Superficial haemorrhages (flame-shaped), seen in RETINAL NERVE FIBRE LAYER (2nd layer of retina) Retinal haemorrhages. Both deep (dot and blot haemorrhages) and superficial haemorrhages (flame-shaped), occurfrom capillary leakage. Superficial retinal haemorrhage may be found in hypeension, diabetes, trauma, venous occlusions,and blood dyscrasias.Deep retinal haemorrhages are typically seen in diabetic retinopathy Subarachnoid haemorrhage may produce retinal haemorrhages especially subhyaloid haemorrhageof the posterior pole Deep Retinal hemorrhages occur in the Outer Plexiform or Inner Nuclear Layers

Ophthalmology

Retina

369ae1fb-c6d1-4a56-a26e-ec1d9b467e27

A person sustains head trauma leading to transection of pituitary stalk. All can be consequence of this, except -

SIADH

Diabetes mellitus

Diabetes incipidus

Hyperprolactinemia

multi

diabetes mellitus is a multi system disorder due to genetic and environmental factors ( Harrison 17 pg 2275)

Medicine

Endocrinology

7f50823b-2df7-4733-b88b-4872490ea81f

Orthostatic hypotension is said to be present, if systolic blood pressure falls by_____while assuming standing posture from sitting posture.

>10 mm Hg

>20 mm Hg

>30 mm Hg

>40 mm Hg

multi

Orthostatic hypotension is defined by a fall in systolic pressure > 20 mmHg or in diastolic pressure > 10  mmHg in response to assumption of the upright posture from a supine position within 3 min. There  may also be a lack of a compensatory tachycardia, an abnormal response that suggests autonomic  insufficiency, as may be seen in patients with diabetes or Parkinson's disease. Orthostatic hypotension  is a common cause of postural lightheadedness/syncope and should be assessed routinely in patients  for whom this diagnosis might pertain. Reference: : Harrison’s medicine page no  126

Medicine

3285ea80-7062-4303-adc8-5f8438a7e9a8

Ankylosing spondylitis in associated with:

HLA-B27

HLA-B47

HLA-DW4/DR4

HLA-DR3

single

SERONEGATIVE SPONDYLOAHROPATHIES Feature HLA B-27 positive/presence of uveitis Onset usually before 45 years age Inflammatory ahritis of spine/large peripheral joints Absence of autoantibodies (e.g. rheumatoid factor) in serum so known as seronegative -Other diseases associated with HLA-B27 positivity Mnemonic: PEARS (HLA-B27 Positive) P- Psoriatic ahritis E- Enteropathic ahritis A- Ankylosing spondylitis(>90%) R- Reiter's syndrome/ Reactive ahritis S- SAPHO Syndrome OTHER OPTIONS: HLA-DW4/DR4- A/W rheumatoid ahritis. HLA-DR3 - A/W Type 1 diabetes mellitus HLA-B47- A/W 21 hydroxylase deficiency

Orthopaedics

Joint disorders

2a76d02e-6bb2-414f-bf1f-92378ae4f979

The following are the contraindications of IUCD except:

Pelvic inflammatory disease

Emergency contraception

Menorrhagia

Diabetes

multi

Contraindications of IUCD: Suspected pregnancy Pelvic inflammatory disease Presence of fibroids Menorrhagia Severe anemia Diabetes Previous ectopic pregnancy Scarred uterus Uterine anomalies Ref: Shaw Gynecology 17 e pg 260.

Gynaecology & Obstetrics

Contraception

dbaea293-b4a9-499f-9fda-43b83a8481ca

All cause diarrhea except;

Diabetes

Hypercalcemia

Hypehyroidism

Irritable bowel syndrome

multi

Hypercalcemia increases the tone of sphincters of the gut leading to refractory constipation. Autonomic dysfunction in diabetes explains the diarrhea. Due to sympathetic activity increase in thyrotoxicosis there is a reduction in small bowel transit time explaining the diarrhea. IBS has variable presentation between diarrhea and constipation

Medicine

Malabsorbtion Syndrome

79ec7a4d-c8e2-4f5a-894c-fde7bda8dc76

Baby with fused eyes and single nasal chamber, undeveloped callosum. What is diagnosis?

Holoprosencephaly

Schizencephaly

Plagiocephaly

Brachycephaly

multi

A i.e. HoloprosencephalyRef: Nelson, Textbook of Pediatrics, 20th edition, page 2640Explanation:HoloprosencephalyDisorder of neuronal migration with defective cleavage of the prosencephalon (the forebrain of the embryo fails to develop into two hemispheres) and inadequate induction of the forebrain structures.Cause - Mutations in the "sonic hedgehog" gene at 7q, maternal diabetes.Three groups:Alobar-Severe facial anomalies, including lack of a nose and the eyes merged to a single median structure, e.g. cyclopia.Semilobar-lntermediate form.Lobar-Least severe formMiddle interhemispheric fusion (MIHF variant) or syntelencephaly - involves a segmental area of non-cleavage of the posterior frontal and parietal lobes.Facial abnormalities - Cyclopia (fused eyes and single nasal chamber), cebocephaly, single central incisor tooth, premaxillary agenesis and anosmia.A prenatal diagnosis - ultrasonography after the 10th week of gestation for more severe types.Other disorder of neural migration:DisorderPathologyClinical featuresLISSENCEPHALY/AGYRIA* Absence of cerebral convolutions, poorly formed sylvian fissure, giving the appearance of a 3-4 months fetal brain* Associated with enlarged lateral ventricles and heterotopias in the white matterPresents with failure to thrive, microcephaly, marked developmental delay, and a severe seizure disorder, hypoplasia of the optic nerve and microphthalmia associated withMiller-Dieker Syndrome (MDS)* Gene LIS-1 (lissencephaly 1) that maps to chromosome region 17p13.3 is deleted* Prominent forehead, bitemporal hollowing, anteverted nostrils, a prominent upper lip, and micrognathia* CT and MRI scans typically show a smooth brain with an absence of sulciSCHIZENCEPHALYPresence of unilateral or bilateral clefts within the cerebral hemispheres* Mental retardation, refractory seizures and microcephaly* Unilateral schizencephaly is a frequent cause of congenital hemiparesis* With spastic quadriparesis when the clefts are bilateral* CT scan is diagnostic and clearly demonstrates the size and extent of the cleftPORENCEPHALYPresence of cysts - in sylvian fissure and typically communicate with the subarachnoid space, the ventricular system, or both, associated with microcephaly, abnormal patterns of adjacent gyri, and ence- phaloceleMental retardation, spastic hemi- or quadriparesis, optic atrophy and seizures.Pseudoporencephalic cysts* Perinatal or postnatal period and result from abnormalities (infarction, hemorrhage) of arterial or venous circulation* Cysts extend to be unilateral* They do not communicate with a fluid-filled cavity; and* They are not associated with abnormalities of cell migration or CNS malformations* Present with hemiparesis and focal seizures in the 1st year of life

Pediatrics

Central Nervous System

31bac2b0-bc21-4e7e-bf70-ca0a2ae8a051

Risk of Pneumococcal meningitis is seen in :

Post splenectomy Patient

Patient undergone neurosurgical intervention

Patient following cardiac surgery

Patient with hypoplasia of lung

single

Ans. is 'a' i.e. Post Splenectomy Patient In table 138-1 p 884 a list of conditions commonly predisposing to pneumococcal infection is given.The list is very long and its not possible to memorize it so I will pick out some important ones for you.Conditions predisposing to pneumococcal infectionsLymphomaMultiple myeloma*Common variable hypogammaglobulinemiaCLLSickle cell disease,* hypersplenia, Asplenia, Splenectomy*Renal insufficiency*Diabetes mellitus*Glucocorticoids administration*Infection with HIVCirrhosis*

Microbiology

Bacteria

053232e4-95d6-4a05-9f65-3ed0d26ea4fb

A 30-year-old woman with diabetes mellitus presents to her physician at 19 weeks' gestation. She is obese and did not realize that she was pregnant until recently. She also has not been "watching her sugar" lately, but is now motivated to improve her regimen. A dilated ophthalmologic examination shows no retinopathy. An ECG is normal. Urinalysis is negative for proteinuria. Laboratory studies show: Hemoglobin A 1c: 10.8% , Glucose: 222 mg/dL , Thyroid-stimulating hormone: 1.0 μU/mL, Free thyroxine: 1.7 ng/dL ,Creatinine: 1.1 mg/dL. In which of the following condition the risk of developing it is same in diabetics as the general population.

Asymptomatic bacteriuria

Preeclampsia

Congenital adrenal hyperplasia

PPH after delivery

single

In the question, patient is presenting with overt diabetes mellitus i.e. she had diabetes before pregnancy also. The question says, in which the following conditions the risk of developing the condition is same in diabetic as well as nondiabetic patients in other words, which of the options is not a complication of diabetes during pregnancy. Option ‘a’ – asymptomatic bacteriuvea – Diabetes during pregnancy, increases the chances of infections including asymptomatic bacteriuria Dutta Obs. 7/e, p 283 Option ‘b’ – preeclampsia – In all diabetic patients, there are increased chances of preeclampsia (25%) Dutta Obs. 7/e p 283 Option ‘c’ – Congenital adrenal hyperplasia – It does not have any relation whatsoever with diabetes. Option ‘d’ – PPH after delivery – Diabetic pregnancy leads to polyhydramnios which can lead to PPH after delivery. Option ‘e’ – Shoulder dystocia is a result of macrosomia during pregnancy.

Gynaecology & Obstetrics

7470ffdc-9e14-4d9c-b8d0-1362b24dab2e

A 29-years-old male taking oral hypoglycemic drug never had ketonuria in his life. His BMI is 20.5. His grandfather had diabetes and his father who is the only son of his grandfather too had the disease. Which type of DM this person will be most likely -

Pancreatic

MODY

Type I

Type II

single

Medicine

6dd0c3e4-b223-4be4-b393-4c32fa585228

A 40 year old male with diabetes presents with vitreous hemorrhage. What is the cause ?

Posterior retinal detachment

Neovascularization at disc

Central retinal vein occlusion

Trauma to central retinal artery

single

This patient is likely to have proliferative diabetic retinopathy in which neovascularization is the hallmark. Neovessels along with fibrous tissue may lie flat on the retina or attach itself to the posterior vitreous face leading later to vitreous face leading later to vitreous traction, retinal separation and the tearing of blood vessels. This is the commonest cause of spontaneous vitreous haemorrhage in adults.

Ophthalmology

1f5fff17-54f7-4ba1-819b-9b21634441b0

Most common type of inheritance associated with consanguinity is?

Autosomal dominant

Autosomal recessive

X-linked dominant

X-linked recessive

single

Ans. is 'b' i.e., Autosomal recessive Consanguinity* Increases risk of - autosomal recessive disease* No change in risk of - autosomal dominant, X linked recessive (if neither parent affected)* Not Proven - complex late onset diseases like diabetes, schizophrenia, cardiovascular diseases

Pathology

Genetics

6e940be2-173b-4a6d-b3c9-cb15e7682c52

Thiazide diuretics can be used for the treatment of all of these conditions EXCEPT

Idiopathic hypercalciuria with nephrocalcinosis

Hyperlipidemia

Congestive Hea Failure

Hypeension

multi

Thiazides cause hyperlipidemia as adverse effect and thus cannot be used to treat this condition. Indications of thiazides: Diuretic Uses: Non-diuretic Uses: Hypeension (First line drugs) Congestive hea failure Diabetes insipidus Idiopathic hypercalciurea with Nephrocalcinosis Loop diuretics cause hypocalcemia by increasing the excretion of Ca2+ whereas thiazides cause hypercalcemia by decreasing its excretion. Thiazides reduce the excretion of Ca++ in the kidney, so can be used for the treatment of patients with hypercalciuria and recurrent Ca++ stones in the kidney.

Pharmacology

Kidney

4f24584f-dd29-4137-9901-8cbe0859b395

All are risk factors for vaginal candidiasis except :

HIV

Hypeension

Pregnancy

Diabetes melitus

multi

Vaginal candidiasis Predisposing factors Diabetes: Increased glycogen in cells leading to increased lactic acid and acidic PH Pregnancy: Increased vaginal acidity Broad spectrum antibiotics Combined oral pills Immunosupression HIV Steroids Thyroid and Parathyroid disease Obesity Ref: D.C.DUTTA'S TEXTBOOK OF GYNAECOLOGY; 6TH Edition; Pg No:164

Gynaecology & Obstetrics

Infections of the genital tract

195ad009-de45-45e9-8e2e-7ed1ed606b84

Baby with recurrent infection of ear & discharge & seborrheic dermatitis with hepatosplenomegaly with cystic skull lesions. Diagnosis is

Hemophagocytic lymphohistiocytosis

Langerhans cell histiocytosis

ALL

Multiple myeloma

multi

In Langerhans Cell Histiocytosis,the most common involvement is of the skeleton(80%).Bone lesions can be single or multiple affecting skull bones,long bones,veebrae,mastoid and mandible.The lesions may be painless or present with pain and local swelling;X rays show sharp lytic lesions.Clinical manifestation includes veebral collapse and spinal compression,pathological fractures in long bones,chronic draining ears and early eruption of teeth.Other manifestations include seborrhoeic skin rash on scalp and back(60%),lymphadenopathy(33%),hepatosplenomegaly(20%),tachypnoea,air leaks,parenchymal lung infiltrates(15%),jaundice,abdominal distension,neurodegenerative symptoms and features of malabsorption.There may also be exophthalmos,pituitary dysfunction producing growth retardation and/or diabetes insipidus,fever,weight loss,malaise,failure to thrive,liver dysfunction,anemia and thrombocytopenia . Image : skull x-ray showing lytic leasions in Langerhans cell histiocytosis . Reference:Essential pediatrics-Ghai,8th edition,page no:620,621.

Pediatrics

Childhood tumors

e8662762-7b8f-4ba7-a429-9f6c6dd4b072

Which of the following should be the line of management in a pregnant female with controlled diabetes?

Even controlled diabetes in pregnancy does not disappear on its own and needs extensive treatment even after delivery

Pregnant females with controlled diabetes are more likely to deliver child by normal vaginal delivery without any complication.

In all females with gestational diabetes, blood sugar levels remain too high, and daily insulin therapy is essential.

LSCS is must in almost every case of gestational diabetes

multi

Ans. b (Pregnant females with controlled diabetes are more likely to deliver child by normal vaginal delivery without any complication). (Ref. Dutta, Obstertics, 6th ed., p 284)DIABETES IN PREGNANCY# Gestational diabetes usually begins in the second half of pregnancy, and goes away after the baby is bom.Effects on the fetus:# Macrosomia# IUGR# Newborns of diabetic mothers are at risk of hypoglycemia, hypocalcemia, hyperbilirubinemia, polycythemia, and hyperviscosity.# Caudal regression syndrome: sacral agenesis (most characteristic feature)# Congenital defects: In pregnancies complicated by type I or II diabetes, the major cause of neonatal mortality is congenital malformation incompatible with life. Therefore, MS AFP should be determined at 16 to 18 wk gestation, and a thorough ultrasound examination should be performed at 18 to 22 wk.# Respiratory distress syndrome# Left lazy colon syndrome# Stillbirth or death as a newborn is rare.# Increased risk of the baby developing type II diabetes or being overweight later in life.Effects on the mother# Women who get gestational diabetes are more likely to develop gestational diabetes in future pregnancies, and are at a higher risk of developing type II diabetes later in life.# Diagnosing gestational diabetes- Urine is routinely tested for sugar throughout pregnancy, and high blood sugar, if present, is usually detected between 24 and 28 weeks of pregnancy.- The only way to confirm gestational diabetes is with a glucose tolerance test, which needs to be carried out after eight hours without food.- When suspected, GTT may be carried out earlier than 24-28 weeks.Q# Treatment- A few women's blood sugar levels remain too high, and they may need daily injections of insulin.- The extra insulin will not cross the placenta and will not affect the baby.- In almost every case, gestational diabetes disappears on its own after delivery.Q# Labor and Delivery- During the 3rd trimester, care of diabetic women consists mainly of controlling maternal plasma glucose levels, assessing fetal well-being, and determining fetal pulmonary maturation.- For most women with gestational diabetes, labor begins spontaneously at term, and delivery is vaginal. If these pregnancies go beyond 42 wk, the fetus is at risk of death in utero, so labor should be induced.- Cesarean section may be necessary in cases of dysfunctional labor or cephalopelvic disproportion or to avoid shoulder dystocia and injury to the newborn and to the birth canal.# Postpartum Care- For women with type I diabetes, insulin requirements decrease dramatically but gradually increase after about 72 h.- Women who have had gestational diabetes should have a 2-h oral glucose tolerance test with 75 g of glucose at 6 to 12 wk postpartum to determine whether they are normal, clearly diabetic, or have impaired glucose tolerance (based on WHO criteria).Educational points:HPL has putative actions in a number of important metabolic processes. These include.1. Maternal lipolysis and an increase in the levels of circulating free fatty acids, thereby providing a source of energy for maternal metabolism and fetal nutrition.2. An anti-insulin or "diabetogenic" action, leading to an increase in maternal levels of insulin, which favors protein synthesis and provides a readily available source of amino acids for transport to the fetus.3. A potent angiogenic hormone; it also may play an important role in the formation of fetal vasculature.

Gynaecology & Obstetrics

Miscellaneous (Gynae)

0e6a007b-3609-4343-9732-a407c7d89cf2

Which of the following is not associated with actions of siuins?

Inhibit metabolic activity

Reduce apoptosis

Increased insulin sensitivity

Reduced by calorie restriction

single

Siuins They are a family of NAD-dependent protein deacetylases. There are at least 7 types They have non-redundant functions designed to adapt bodily functions to various environmental stresses, including Food deprivation and DNA damage. Functions:- These include proteins that inhibit metabolic activity Reduce apoptosis Stimulate protein folding Inhibit the harmful effects of oxygen free radicals. Siuins also increase insulin sensitivity and glucose metabolism, and may be targets for the treatment of diabetes.

Pathology

Miscellaneous

19aa01af-f8ce-471f-8071-fd9d0f201500

Calculus is most commonly seen in which salivary gland:

Sublingual

Palatal

Parotid

Submandibular

single

Stone formation is most common in submaxillary (submandibular) gland (80-90% cases) followed by parotid gland (10-20%). It can occur at any age with a predilection for men. Predisposing factors for stone formation are systemic disease (Hyperparathyroidism, hypercalcemia, gout, diabetes and hypeension) therefore submandibular calculi contain primarily calcium phosphate and hydroxyapatite and are radiopaque and visualized on X-ray Parotid gland calculi are less radiopaque M/C presentation - Recurrent swelling and pain in the submandibular gland exacerbated with eating. IOC to detect stones - CT scan Sialography is not done routinely and is contraindicated in a patient of sialadenitis. Management Depending on the size of stone and the site at which it is located, it can be removed by: Intraoral extraction Surgical excision Endoscopic removal

ENT

8f1e28e3-93f6-4c48-b76e-ec6fef6d2ea4

Which of the following is not associated with Diabetes mellitus?

Cushing's syndrome

Acromegaly

Hypothyroidism

Pheochromocytoma

single

ANSWER: (C) HypothyroidismREF: Harrison's 18th ed ch: 344Endocrinopathies associated with Diabetes are:AcromegalyCushings syndromeGlucagonomaPheochromocytomaHyperthyroidismSomatostatinomaAldosteronoma

Medicine

Diabites & Inappropriate Antidiuretic Hormone

1b82f4c1-2935-4e89-a221-bfd82f28c4d3

Amyloidosis is most commonly seen in ?

Maturity onset DM

Type I DM

Type H DM

HTN

single

Ans. is 'c' i.e., Type II DMo The two best examples of localized amyloidosis are Alzheimer's disease and type 2 diabetes mellitus.o Localized amyloid deposition results from the production of a unique polypeptide, which contains an amyloidogenicsequence and is capable of forming a beta-pleated sheet structure necessary for these deposits to aggregate. o In type 2 diabetes it is the islet amyloid polypeptide (IAPP) also known as amylin.o In Alzheimer's the unique peptide is the beta-amyloid protein (A beta).

Pathology

30589b9b-870b-48c2-9512-ad9fcf68bd28

A 60-year-old woman with type 2 diabetes and end-stage renal disease receives a kidney transplant. Three weeks later, the patient presents with azotemia and oliguria. If this patient has developed acute renal failure, which of the following pathologic findings would be expected on renal biopsy?

Aerial intimal thickening and vascular stenosis

Glomerulosclerosis

Interstitial infiltrates of lymphocytes and macrophages

Neutrophilic vasculitis and fibrinoid necrosis

single

Transplant rejection reactions have been traditionally categorized into:- Hyperacute Acute Chronic rejection based on the clinical tempo of the response and on the mechanisms involved. Acute rejection is characterized by an abrupt onset of azotemia and oliguria, which may be associated with fever and graft tenderness. A needle biopsy would be expected to show Interstitial infiltrates of lymphocytes and macrophages Edema Lymphocytic tubulitis Tubular necrosis. Neutrophilic vasculitis and fibrinoid necrosis (choice D) are seen in hyperacute rejection. Diagnosis: Acute graft rejection

Pathology

Organ Transplant / Graft

e88634e9-3442-4999-bbaa-ee518b6b6dab

Most common pathological features in diabetes melitus is -

Papillary necrosis

Diffuse glomerulosclerosis

Renal atherosclerosis

Chronic pyelonephritis

single

Pathology

abfcb3fd-ad28-4155-abd0-def8d2de879e

Which line represent the disease directly causing death, in death certificated -

Ia

Ib

Ic

II

single

Ans. is 'a' i.e., Ia * The basis of mortality data is death certificate. For ensuring national and international comparability, it is necessary to have a uniform and standardized system of recording and classifying deaths. For this purpose WHO has recommended international death certificate.* Consist of four lines:-# Line Ia: Disease or condition directly leading to death# Line Ib: Antecedent/ underlying cause# Line Ic: Main antecedent / underlying cause# Line II: Other significant conditions contributing to death but not related to disease! condition causing it* Example of a death certificate:-# Line Ia: Renal failure# Line Ib: Diabetic nephropathy# Line Ic: Diabetes mellitus# Line II: Hypertension* Concept of underlying cause, Line Ic is the most important line in death certificate, thus also known as 'Essence of Death Certificate\

Social & Preventive Medicine

Concept of Health and Disease

1217d11a-33bd-4b4d-8328-255508e6a865

Caudal regression syndrome is seen in babies of mother having:

Diabetes

PIH

Cardiac disease

Anaemia

single

Ans. is a, i.e. DiabetesRef. Fernando Arias 3/e, p 454; COGDT 10/e, p 312"The lesion classically associated with diabetic embryopathy, the 'caudal regression syndrome', is rare, with an incidence of 1.3 per 1000 diabetic pregnancies". --Fernando Arias 3/e, p 454

Gynaecology & Obstetrics

Medical & Surgical Illness Complication Pregnancy

65b7720c-d00c-4eba-9ab8-fcdecf1e7177

The skin pigmentation in bronze diabetes is due to-

Hemosiderin

Lipofuscin

Melanin

Both melanin & hemosiderin

multi

Skin pigmentation in bronze diabetes (Hemochromatosis) →Predominantly due to increased epidermal melanin production →Partly attributed to hemosiderin deposition in dermal macrophages and fibroblasts.

Pathology

8bb5296e-eb37-4862-a7b1-81ddf0504101

Commonest histological finding in benign hypertension is

Proliferative endarteritis

Necrotizing arteriolitis

Hyaline arteriosclerosis

Cystic medial necrosis

single

(C) (Hyaline arteriosclerosis) (495, 96- Robbins 8th) (678- Harshmohan 7th)* Hyaline arteriosclerosis consists of homogenous pink hyaline thickening of the wall of the arterioles with loss of underlying structural detail.* Encountered frequently in elderly patients whether normotensive, or hypertensive hyaline arterioscleroses is more generalized and more severe in patents with hypertensionQ* It is also common in diabetesQ as a part of the characteristic microangiopathy.Pathogenesis* The lesion reflects leakage of plasma components across vascular endothelium and excessive extra cellular matrix production by smooth muscle cells secondary to the chronic hemodynamic stress of hypertension or a metabolic stress in diabetes that accentuates endothelial cell injury.Also knowHyperplastic arteriosclerosis* It is characteristic of malignant hypertensionQ.* There is concentric laminated thickening of arteriolar wall - onion thickening0.* There is mucinous intimal thickening and fibrous intimal thickening.* There may be accompanied fibrinoid deposite with necrosis of the vessel wall - fibrinoid necrosisThe characteristic histological finding in Benign Hypertension is Hyaline arteriosclerosisBenign NephrosclerosisMalignant NephrosclerosisThis term is used do describe the charges in kidney associated with benign phase of hypertensionThis term is used to describe the changes in kidney associated with malignant or accelerated hypertensionGrossGross* Kidney size is normal 0 or may be moderately reduced 0* Kidnev size is variable0 mav be smaller in size0 (when superimposed on benign nephrosclerosis) or Larger in size (enlarged)0 than normal (patents who develop malignant hypertension in pure form* Grain leather appearance0. The cortical surface has a fine even granularity* Flen bitten appearance0The cortical surface may show multiple small peticheal haemorrhages0 from rupture of arterioles or glomerular capillariesMicroscopic (vascular changes & parenchymal (changes)Microscopic (cascular changes & parenchymal changes)* Hvaline Arteriosclerosis0 Narrowing of the lumens of arterioles and small arteries caused by thickening and hyalinization of the walls* Fibrinoid necrosis of arterioles (Necrotizing arteriolitis0)The vessel wall showa fibrinoid necrosis.Represents an acute event and necrosis is usually not accompanied by intense inflammation* Fibroelastic Hyperplasia, In the intima (intimal thickenningQ). duplication of elastic lamina and hypertrophy of the 'media'* Hyperplastic intimal sclerosis /onion - Skinning Concentric laminae of proliferated smooth muscle cells collagen and basement membrane (producing intimal thickening)* Parenchymal chances (due to ischaemic) Variable degree of Atrophy of parenchyma & due to ischaemia* Parenchymal chances (due to ischaemia)Variable degree of atrophy of parenchyma due to ischaemia infarction necrosis distalQ abnormal vessels may be seen* Fibroid necrosis may be seen in- Polyarteritis nodosa (PAN)- Aschoff's nodule- Malignant hypertension

Pathology

Blood Vessels

b21c20fd-0507-4b4b-b813-6c556493ac70

All the following are risk factors for fetal overgrowth except

Obesity

Diabetes

Primiparity

Previous macrosomic infant

multi

Risk Factors for Fetal OvergrowthObesityDiabetesPostterm gestationMultiparityLarge size of parentsAdvancing maternal agePrevious macrosomic infantRacial and ethnic factorsReference: William's Obstetrics; 25th edition; Chapter 44; Fetal-Growth Disorders

Gynaecology & Obstetrics

General obstetrics

e3a10215-08ea-4b47-93a8-9588d668aad1

Thiazides false is

Used in CCF

Causes hyperglycemia

Increases uric acid concentration in serum

Increases calcium excretion in urine

multi

Ans. is 'd' i.e. Increases calcium excretion in urine Thiazides are moderate efficacy diureticsThey inhibit NaCl reabsorption from the luminal side of epithelial cells in the DCT by blocking the Na+Cl- transporterThiazides increase calcium reabsorption in the kidney tubules thus, decreasing calcium excretion. But thiazides rarely cause hypercalcemia as a result of this enhanced reabsorption, they can unmask hypercalcemia due to other causes.This effect on calcium makes them useful in the t/t of kidney stones caused by idiopathic hypercalciuria.Major indications of thiazide diuretics:-HypertensionHeart failureNephrolithiasis due to idiopathic hypercalciuriaNephrogenic diabetes insipidusAdverse effect of thiazide diuretics Hypokalemic metabolic alkalosisDue to the action of thiazides, more salts are delivered to the collecting tubule. Increased delivery leads to increased secretion of K+ and H+ by the duct causing hypokalemic metabolic alkalosis.Impaired carbohydrate tolerance (Hyperglycemia)Hyperglycemia may occur in patients who are overtly diabetic or who have even mildly abnormal glucose tolerance tests.The effect is due to both impaired pancreatic release of insulin and diminished utilization of glucose. HyperlipidemiaThiazides cause a 5-15% increase in total serum cholesterol and low density lipoproteins (LDL) HyperuricemiaThiazides cause increased reabsorption of uric acid.HyponatremiaIt is due to combination of hypovolemia induced elevation of ADH, reduction in the diluting capacity of the kidney and increased thirst.Allergic reactionsThe thiazides are sulfonamides and they share cross-relativity with other members of this group. Photosensitivity or generalized dermatitis occurs rarely. Serious allergic reactions are extremely rare but do include hemolytic anemia, thrombocytopenia and acute necrotizing pancreatitis.Other toxicitiesWeakness, fatigability and paresthesiasContraindications of thiazide diureticsHepatic cirrhosisBorderline renal failure

Pharmacology

Diuretic

3403682a-d59a-4a82-a8ee-53ce376fd49f

A 23-year-old woman is noticed to have irregular pupils on routine examination. She has one large pupil, which has minimal response to light stimulation, but it does respond to accommodation. The eye movements are normal and she experiences no double vision.For the above patient with a pupillary abnormality, select the most likely diagnosis

essential anisocoria

Horner syndrome

tonic pupils (Holmes-Adie syndrome)

Argyll Robertson pupils

multi

The tonic pupil (Holmes-Adie syndrome) is caused by a parasympathetic lesion at or distal to the ciliary ganglion. The pupil is large and usually unilateral, with absent response to light. A bright room, by causing constriction of the normal pupil, accentuates the anisocoria. The tonic pupil can be associated with Shy-Drager syndrome, amyloidosis, or diabetes. However, it is most commonly seen in otherwise healthy young women.

Medicine

C.N.S.

89e26485-c1cd-4a5b-bfb5-708e8ba69139

A patient presents with symptoms of Hypoglycemia. Investigations reveal decreased blood glucose and increased Insulin levels. C-peptide assay is done which shows normal levels of C-peptide. The most likely diagnosis is:

Insulinoma

Accidental sulfonylurea ingestion

Accidental exogenous Insulin administration

Accidental Metformin ingestion

single

For the production of insulin enzymes in the pancreatic beta cells cleave the proinsulin molecule into insulin and C peptide, which are both present in insulin granules and are released in equimolar amounts when insulin is secreted into blood stream. In accidental exogenous Insulin administration, beta cell function is normal, and the release of endogenous insulin as well as C peptide is suppressed by the low circulating glucose level. Ref: Joslin's diabetes mellitus By Elliott Proctor Joslin, C. Ronald Kahn page1160; Clinical endocrinology By Ashley Grossman page 534; Problem solving in clinical medicine: from data to diagnosis By Paul Cutler page 204; Criminal poisoning: clinical and forensic perspectives By Christopher P. Holstege page 94

Medicine

c0917ebf-3273-4193-ab29-34fd2298e92e

Which one of the following clinical situation would be LEAST likely to result in a newborn who is small for gestational age?

Premature rupture of the membranes

Abruptio placentae

Congential CMV infection

Gestational diabetes mellitus

multi

Pregnancies associated with, gestational diabetes mellitus usually produce newborns that are large for gestational age (macrosomia). Hyperglycemia in the mother causes fetal release of insulin, which increases the synthesis of fat and muscle. Fetal, placental, and maternal causes can result in a newborn that is small for gestational age. Fetal abnormalities include chromosome disorders, congenital anomalies, and infection. Placental abnormalities (uteroplacental insufficiency) can result from infection, infarction, abruption placenta, and premature rupture of the membranes. Maternal factors are most common and include pregnancy-induced hypeension (preeclampsia), malnutrition, smoking, alcohol consumption, and drug addiction.

Surgery

697e3742-6f7f-41f6-ba65-01a10c8a6cce

A multigravida at 35 weeks' gestation had the following finding on ultrasound. The following can be the causes except:

Diabetes

Posterior urethral valve

Rh alloimmunization

Anencephaly

multi

Ans. B. Posterior urethral valvePolyhydramnios is diagnosed when the AFI >24cm or the single deepest pocket measures >8cm.Causes of polyhydramnios:a. MC cause of mild polyhydramnios = idiopathicb. Multifetal pregnancyc. Maternal diabetesd. Cleft lip/palate (GIT anomalies >NTD)e. Esophageal atresia/duodenal atresiaf. Anencephalyg. Chorangioma of placentah. Hydrops fetalis (Rh alloimmunization)i. TORCHj. Trisomyk. sacrococcygeal teratoma

Gynaecology & Obstetrics

Miscellaneous (Obs)

12e02b09-e2a1-425f-8796-6c5b96300221

Which of the following drug is used in myocardial infarction

Cocaine

Pethidine

Morphine

Butarphanol

single

Refer kDT 7/e 556 Treatment depends on severity Treatment ranges from lifestyle changes and cardiac rehabilitation to medication, stents and bypass surgery. Suppoive care Defibrillation Using an electrical shock to correct a rapid, irregular heabeat and restore the hea's normal rhythm. Oxygen therapy Providing extra oxygen to the lungs of people with breathing problems. Medications Blood Thinners Helps prevent blood clots from forming or helps dissolve existing clots. Hea Medication Helps reduce chest pain or pressure caused by blockages in the aeries of the hea. Narcotic Relieves pain, dulls the senses and causes drowsiness. May become addictive. Beta blocker Slows hea rate and decreases blood pressure. When taken in eye-drop form, it reduces eye pressure. Statin Decreases the liver's production of harmful cholesterol. ACE inhibitor Relaxes blood vessels, lowers blood pressure and prevents diabetes-related kidney damage. Medical procedure Coronary stent and Coronary angioplasty Therapies Cardiac rehabilitation Surgery Coronary aery bypass surgery

Anatomy

General anatomy

7b3874b9-9f0f-4c0c-a12c-69aa6afa59a6

A 23 year old female with type I diabetes presented with 6 weeks of amenorrhea. Her urine pregnancy test turned to be positive. Her sugar levels are not in control. The child may have all of the following abnormalities, EXCEPT:

Chromosomal abnormalities

Caudal regression

Renal agenesis

Duplex ureter

multi

Diabetes is not associated with increased risk for fetal chromosomal abnormalities. Congenital malformations in infants of women with ove diabetes: Caudal regression Situs inversus Spina bifida, hydrocephaly, or other central nervous system defects Anencephaly Cardiac anomalies Anal/rectal atresia Renal anomalies Agenesis Cystic kidney Duplex ureter Ref: Cunningham F.G., Leveno K.J., Bloom S.L., Hauth J.C., Rouse D.J., Spong C.Y. (2010). Chapter 52. Diabetes. In F.G. Cunningham, K.J. Leveno, S.L. Bloom, J.C. Hauth, D.J. Rouse, C.Y. Spong (Eds), Williams Obstetrics, 23e.

Gynaecology & Obstetrics

271febf6-1650-4007-b2ce-323382e7e8f3

A person with type 1 diabetes ran out of her prescription insulin and has not been able to inject insulin for the past 3 days. An overproduction of which of the following could cause a metabolic acidosis?

Hb

Ketone bodies

HCl

Bicarbonate

single

Ketone bodies are weak acids. In diabetic ketoacidosis, the liver produces ketone bodies, which will reduce the brain's dependency on glucose as its sole energy source. This is due to the lack of insulin and the liver switching to starvation mode owing to the constant signaling by glucagon. Hb in the red blood cells and bicarbonate, both in the red blood cells and the plasma, are two of the body's major buffers, and their overproduction would not lead to an acidosis. HCl overproduction within the stomach might lead to duodenal ulcers or gastroesophageal reflux, but not to an overall metabolic acidosis, because the protons do not find their way into the circulation. A loss of chloride, if severe enough, could produce a metabolic alkalosis, but not an acidosis.

Biochemistry

Miscellaneous (Bio-Chemistry)

7baa97b4-5625-4528-9779-9fcf99cc8fc5

Which of the following is required for proper effects of Insulin?

Selenium

Iron

Copper

Chromium

single

In association with insulin, chromium promotes the utilization of glucose Chromium is a component of a protein namely chromodulin which facilitates the binding of insulin to cell receptor sites Chromium It is an essential nutrient for the maintenance of normal glucose tolerance Its deficiency causes insulin resistance. Chromium administration has also been shown in several studies to lower glucose and insulin levels in patients with type 2 diabetes. It has been classified as not essential for mammals. (Cr (III) or Cr3+). Ref: Guyton 12th Ed.

Physiology

All India exam

ecc9864a-c7e3-4e4f-92d1-656190de8569

which of the following can be used to differentiate between diabetes mellitus type 1 and 2?

Association with All 3/4

Presence or absence of insulitis

Insulin levels

All the above

multi

Answer- D. All the aboveAge- <20 yearsAutoimmune destruction of Beta cells mediated by T cells and humoral mediators. Anti islet cell antibodies.Islet cells- Early Insulitis, marked atrophy and fibrosis, Beta cell depletion.Marked decrease blood insulin.

Medicine

dab15a07-54c8-4700-a0ac-6ac99c09fefb

Ideal time for doing Quadruple test?

15-18 weeks

12-14 weeks

10-12 weeks

8-10 weeks

single

Ref. The Short Textbook of Pediatrics. Pg 600   Triple and Quadruple test The triple screening measures the amounts of three substances in a pregnant woman's blood: alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), and estriol (uE3) The quad screen test is a maternal blood screening test that looks for four specific substances: AFP , hCG , Estriol, and Inhibin-A Indications Have a family history of birth defects Are 35 years or older Used possible harmful medications or drugs during pregnancy Have diabetes and use insulin Had a viral infection during pregnancy Have been exposed to high levels of radiation Timing The triple screen test is performed between the 15th and 18th week of pregnancy

Unknown

3f21f255-42e5-44fe-8e15-1fa684276ce3

A 19-year-old male has a history of athlete's foot but is otherwise healthy when he develops the sudden onset of fever and pain in the right foot and leg. On physical exam, the foot and leg are fiery red with a well-defined indurated margin that appears to be rapidly advancing. There is tender inguinal lymphadenopathy. The most likely organism to cause this infection is

Staphylococcus epidermidis

Tinea pedis

Streptococcus pyogenes

Mixed anaerobic infection

single

(Braunwald, 15/e, pp 823, 893.) Erysipelas, the cellulitis described, is typical of infection caused by S.Pyogenes - Group A b- hemolytic Streptococci (GAS). There is often a preceding event such as a cut in the skin, dermatitis, or superficial fungal infection that precedes this rapidly spreading cellulitis. Anaerobic cellulitis is more often associated with underlying diabetes. S. epidermidis does not cause rapidly progressive cellulitis. Staphylococcus aureus can cause cellulitis that is difficult to distin guish from erysipelas, but it is usually more focal and likely to produce furuncles, or abscesses.

Surgery

291c2421-fc07-4efe-8bf7-fa8325fbd219

SARS - false statement is

Incubation period is 10 to 15 days

Affects CD8 + T cells than CD4 + T cells

Constipation is marked during first 3 days

All of the above

multi

(D) All of the above # CLINICAL MANIFESTATIONS: After an incubation period that generally lasts 2 to 7 days (range, 1 to 10 days), SARS usually begins as a systemic illness marked by the onset of fever, which is often accompanied by malaise, headache, and myalgias and is followed in 1 to 2 days by a nonproductive cough and dyspnea.> Approximately 25% of patients have diarrhea. Chest x-rays can show a variety of infiltrates, including patchy areas of consolidation--most frequently in peripheral and lower lung fields--or interstitial infiltrates, which can progress to diffuse involvement.> In severe cases, respiratory function may worsen during the second week of illness and progress to frank adult respiratory distress syndrome (ARDS) accompanied by multiorgan dysfunction. Risk factors for severity of disease include an age of 50 and comorbidities such as cardiovascular disease, diabetes, or hepatitis.> Illness in pregnant women may be particularly severe, but SARS-CoV infection appears to be milder in children than in adults.> Laboratory abnormalities in SARS include lymphopenia, which is present in -50% of cases and which mostly affects CD4+ T cells but also involves CD8+ T cells and NK cells.> Total white blood cell counts are normal or slightly low, and thrombocytopenia may develop as the illness progresses.> Elevated serum levels of aminotransferases, creatine kinase, and lactate dehydrogenase have been reported.

Medicine

Miscellaneous

90d4dbec-4e3d-42df-8bfa-af962858ff3e

Diet devoid of carbohydrates causes:

Ketosis

DM

No effect

Obesity

single

A i.e. KetosisThree conditions lead to deficient intracellular glucose supplies & hence to ketoacidosis: Starvation, DM (Diabetes Mellitus) and high fat low carbohydrate dietQ.Low carbohydrate diet Cause defective intracellular glucose supply, and most of the calories are supplied by fat.When there is high rate of fatty acid oxidation the ketone bodies are formed in hepatic mitochondria to provide calories (ATP) & they accumulate in blood (ketosis)Q.- Ketone bodies are impoant fuel in extrahepatic tissue.* Small amount of glucose abolishes the ketosis & for this reson carbohydrate is said to be antiketogenicQ.

Physiology

2c8e8a0f-0b5f-45c7-8b63-242fb584f612

Which of the following is increased in lipoprotein lipase deficiency?

VLDL

LDL

HDL

Chylomicrons

single

Lipoprotein lipase deficiency (Type I hyperlipoproteinemia): is a rare, autosomal recessive disorder caused by a deficiency of lipoprotein lipase.Resulting in fasting chylomicronemia and hyperiglycerolemia.There is slow clearance of chylomicrons and VLDL. Low levels of LDL and HDL. There is no increased risk of coronary disease. Lipoprotein lipase (LPL): is a glycoprotein anchored to proteoglycans that decorate the capillary endothelial surfaces of adipose tissue, hea and skeletal muscle. The triglycerides of chylomicrons are hydrolyzed by LPL, and free fatty acids are released. ApoC-II, which is transferred to circulating chylomicrons from HDL, acts as a cofactor for LPL in this reaction. LPL deficiency has autosomal recessive inheritance. Both LPL and apoC-II deficiency usually present in childhood with recurrent episodes of severe abdominal pain due to acute pancreatitis. Deficiency leads to Increase TG & Increase Chylomicrons Chylomicrons are grossly increased and there is slow clearing of chylomicrons VLDL is also increased (but chylomicrons dominate). Decrease in LDL and Hdl DL Hyperlipoproteinemias Disease Inheritance Defect Elevated Lipoproteins and lipids Familial lipoprotein lipase deficiency (type I) AR Deficiency of LPL, abnormal LPL, or apo C-II deficiency causing inactive LPL. Increased TG and chylomicrons Slow clearance of chylomicrons and VLDL. Low levels of LDL and HDL. No increased risk of coronary disease. Familial hypercholesterolemia (type IIa) AD Defective LDL receptors or mutation in ligand region of apo B-100. Increased cholesterol Elevated LDL Results in atherosclerosis and coronary disease. Familial combined hyperlipidemia (type IIb) Unknown Excessive VLDL secretion from increased ApoB100 and LDL (decreased LDL receptor) Increased LDL and VLDL. Familial type III hyperlipoproteinemia (broad beta disease, remnant removal disease, familial dysbetalipoproteinemia Deficiency in remnant clearance by the liver is due to abnormality in apo E. Patients lack isoforms E3 and E4 and have only E2, which does not react with the E receptor. Increase in chylomicron and VLDL remnants of density < 1.019 (VLDL). G and cholesterol Causes hypercholesterolemia, xanthomas, and atherosclerosis. Familial hyperiacylglyceridemia (type IV) AD Overproduction of VLDL often associated with glucose intolerance and hyperinsulinemia. Cholesterol levels rise with the VLDL concentration. LDL and HDL tend to be subnormal. This type of pattern is commonly associated with coronary hea disease, type II diabetes mellitus, obesity, alcoholism, and administration of progestational hormones. Endogenous hyperiglyceridemia (Type V) Chylomicrons and VLDL Glucose intolerance and hyperuricemia Ref: Chatterjee Shide. 4th Editon, p374

Biochemistry

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A 26-year-old woman with a 6-month history of depression accompanied by active suicidal ideation ingests 35 g of acetaminophen. She quickly experiences nausea and vomiting. Within 1 day, she becomes progressively obtunded. On physical examination, her temperature is 36.9deg C, pulse is 75/min, respirations are 15/min, and blood pressure is 100/65 mm Hg. She is treated with N-acetylcysteine. Depletion of which of the following is most likely to accentuate her organ damage?

Glutathione (GSH)

Amylase

Creatine kinase

Ketone bodies

single

Acetaminophen toxicity leads to hepatic necrosis, indicated by rising ALT and AST levels. If death is not immediate, hyperbilirubinemia also can be seen. N-Acetylcysteine augments glutathione by contributing a sulfhydryl group for binding to toxic metabolites. Elevated serum amylase is seen in pancreatitis. Elevated serum creatine kinase is seen with injury to skeletal and cardiac muscle. Ketonuria is a feature of absolute insulin deficiency in diabetes mellitus; it also is a feature of starvation. Hypokalemia can be a feature of renal diseases and glucocorticoid deficiency.

Pathology

Environment & Nutritional Pathology

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A 34 weeks pregnant female with increased urinary frequency diagnosed of having transient-diabetes insipidus. This patient may have the following associated pathology:

Severe pre-eclampsia

Hydramnios

Multiple pregnancy

IUGR

single

The development of new-onset diabetes insipidus in the third trimester is usually due to increased vasopressinase activity either due to increased placental production or decreased hepatic vasopressinase metabolism due to liver damage from various causes including preeclampsia, acute fatty liver of pregnancy, or HELLP, syndrome. This phenomenon is called transient vasopressin-resistant diabetes insipidus (DI) of pregnancy. Ref: Mehta N.D., Chen K.K., Monzon C., Rosene-Montella K. (2012). Chapter 223. Common Medical Problems in Pregnancy. In G.V. Lawry, J. Matloff, D.D. Dressler, D.J. Brotman, J.S. Ginsberg (Eds), Principles and Practice of Hospital Medicine.

Gynaecology & Obstetrics

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Macrosomia is/are associated with:a) Gestational diabetes mellitusb) Maternal obesityc) Hypothyroidism d) Hyperbilirubinemia e) Fetal goitre

ac

a

ad

ab

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The recommended definition is fetal (neonatal) weight exceeding two standard deviations or above 90th centile for the appropriate normal population. According to ACOG: birth weight of > 4500 gm is called as macrosomia. In Indian context birth weight of > 4000 gm is called as macrosomia.

Gynaecology & Obstetrics

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A 25-year-old woman presents with intermittent symptoms of sweating, palpitations, and hunger. During each episode, her glucose level is less than 40 mg/dL. Her insulin level is low and glucagon level is high. Which of the following best describes the hormone function of glucagon?

promotes glycogenolysis and gluconeogenesis

a carbohydrate in structure

effective in lowering blood sugar levels

antigenically similar to insulin

multi

This person has either fasting or reactive hypoglycemia. Glucagon exerts a marked effect on carbohydrate, fat, and lipid metabolism, and increases cAMP in many tissues. It is the first counterregulatory hormone to respond to hypoglycemia, and it does this by increasing glycogenolysis and gluconeogenesis. Glucagonomas of the pancreas present with features such as mild diabetes mellitus (DM), psychiatric disturbances, diarrhea, venous thromboses, and skin findings (necrolytic migratory erythema).

Medicine

Endocrinology

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Which of the following disease is also known as diabetic diarrhea:

Whipple disease

Ulcerative colitis

Coeliac disease

Carcinoid Syndrome

single

Ans. C. Coeliac DiseaseAutoimmune disease having associated diabetesa. Chronic lymphocytic thyroiditis (Hashimoto)b. Celiac disease (Hence celiac disease is also known as diabetic diarrhea)c. Multiple endocrine deficiency syndrome

Medicine

G.I.T.

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Most common cause of chronic kidney disease

Diabetes mellitus

Hypertension

PCKD

Hepatorenal Syndrome

single

Most common cause - Diabetes mellitus

Medicine

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All are true about cystic fibrosis except?

Recurrent respiratory infections

Majority of males are infertile

Fasting hyperglycemia is a feature of early disease

Sweat chloride is >70 meq/1

multi

Ans. (c) Fasting hyperglycemia is a feature of early disease(Ref: Refer Ans 7 & 10; Nelson 19th/pg 1996; Robbins 9th/pg 466-470; 8th/pg 465-470)Cystic fibrosis-related diabetes (CFRD)No diabetes is seen in CF patients younger than 10 yr while 40-50% show diabetes at >=20yr age;So diabetes is a late feature of CF, seen only in individuals who survive to adolescence & beyond.Patients with CFRD have features of both T1DM and T2DM.There is pancreatic damage leading to slowly progressive insulin deficiency, along with insulin resistance

Pathology

Disease of Infancy & Childhood

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Which one of the following medical disorders leads to delayed foetal lung maturity -

Hea disease

Diabetes

Thalassemia minor

Epilepsy

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Ans. is 'b' i.e., Diabetes o Maternal diabetes predisposes to HMD.

Pediatrics

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Puerperal sepsis/infection occurs up to?

1 week

2 week

3 week

4 week

single

Ans- B 2 week PUERPERAL SEPSIS DEFINITION Puerperal sepsis is any bacterial infection of the genital tract which occurs after the birth of a baby. It is usually more than 24 hours after delivery before the symptoms and signs appear. Some of the most common bacteria are: streptococci staphylococci escherichia coli (E.coli) clostridium tetani clostridium welchii chlamydia gonococci SYMPTOMS AND SIGNS are fever (temperature of 38degC or more) chills and general malaise lower abdominal pain tender uterus subinvolution of the uterus purulent, foul-smelling lochia. light vaginal bleeding shock. RISK FACTORS Some women are more vulnerable to puerperal sepsis, including anaemia and/or malnourished, protracted labour, prolonged rupture of the membranes, frequent vaginal examinations, a traumatic delivery, caesarean section and retained placental fragments, PPH, diabetes all predispose to puerperal infection. SITES The most common site of infection in puerperal sepsis is the placental site. Other sites of infection are abdominal and perineal wounds following surgery and lacerations of the genital tract, e.g. cervix, vagina and perineum. Following delivery, puerperal sepsis may be localized in the perineum, vagina, cervix or uterus. Infection of the uterus can spread rapidly if due to virulent organisms, or if the mother's resistance is impaired. It can extend beyond the uterus to involve the fallopian tubes and ovaries, to the pelvic cellular tissue causing parametritis , to the pelvic peritoneum, causing peritonitis , and into the blood stream causing septicaemia DIFFERENTIAL DIAGNOSIS Fever in the puerperium can also be caused by: urinary tract infection (acute pyelonephritis) wound infection (e.g. scar of caesarean section) mastitis or breast abscess thrombo-embolic disorders, e.g. thrombophlebitis or deep vein thrombosis respiratory tract infections

Unknown

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The MOST common organism isolated in emphysematous pyelonephritis is:

E. coli

Proteus

Pseudomonas

Klebsiella

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Emphysematous pyelonephritis is a form of acute necrotizing pyelonephritis secondary to a gas-producing bacteria (E coli in 66% of cases and Klebsiella in 26%). It is commonly seen in patients with poorly controlled diabetes (over 90% of cases) or in patients with upper urinary tract obstruction. The diagnosis is made by the usual signs of acute pyelonephritis and by the presence of gas in the renal collecting system and parenchyma seen on plain films, ultrasound, or CT. The condition is life threatening. Operative treatment, including nephrectomy and drainage along with antibiotics, decreases the moality rate. Ref: Cooper C.S., Joudi F.N., Williams R.D. (2010). Chapter 38. Urology. In G.M. Dohey (Ed), CURRENT Diagnosis & Treatment: Surgery, 13e.

Microbiology